Thrombosed External Hemorrhoid Excision

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External hemorrhoids (piles) occur distal to the dentate line and develop as a result of distention and swelling of the external hemorrhoidal venous system (see the first image below). ^[1] Engorgement of a hemorrhoidal vessel with acute swelling may allow blood to pool and, subsequently, clot; this leads to the acutely thrombosed external hemorrhoid, a bluish-purplish discoloration often accompanied by severe incapacitating pain (see the second image below).

Thrombosed external hemorrhoids are a common problem but remain a poorly studied topic. Reported risk factors for thrombosed external hemorrhoid include a recent bout of constipation ^{[2, 3]} and traumatic vaginal delivery. ^{[4, 5]}

Although conservative nonsurgical treatment (stool softeners, increased dietary fiber, increased fluid intake, warm baths, analgesia) ultimately results in improvement of symptoms for most patients, surgical excision of the thrombosed external hemorrhoid often precipitates resolution. ^{[6, 7, 8]}

Newer conservative treatments, such as topical nifedipine, show promise of having advantages over traditional conservative treatments, such as lidocaine ointment ^[9] ; however, in comparison with surgical excision, they have not yet been shown to shorten the time to symptom resolution or reduce the frequency of recurrence.

Surgical excision of the acutely thrombosed external hemorrhoid is within the purview of an office-based or emergency practitioner. ^{[10, 11]} This safe procedure offers low recurrence and complication rates and high levels of patient acceptance and satisfaction. ^[12]

Go to Hemorrhoids and Anal Surgery for Hemorrhoids for complete information on these topics.

Acute pain and thrombosis of an external hemorrhoid within 48-72 hours of onset is an indication for excision.

In a retrospective study by Greenspon et al, surgical treatment resulted in much faster symptom resolution (3.9 days vs 24 days), as well as a lower frequency of recurrence (6.3% vs 25.4%), in the study population. ^[13] A study by Cavcić et al demonstrated that in comparison with simple incision or topically applied 0.2% glycerin trinitrate ointment, thrombosed external hemorrhoid excision improved recurrence rates, symptoms, and residual skin tags at 1-year follow-up. ^[14]

Absolute contraindications to thrombosed external hemorrhoid excision in the emergency department (ED) include the following:

Relative contraindications to ED excision of a thrombosed external hemorrhoid include the following:

Abdelnaby A, Downs JM. Diseases of the anorectum. Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 10th ed. Philadelphia: Elsevier Saunders; 2016. Vol 2: 2316-38.

Oh C. Acute thrombosed external hemorrhoids. Mt Sinai J Med. 1989 Jan. 56 (1):30-2. [Medline].

Tan KY, Seow-Choen F. Fiber and colorectal diseases: separating fact from fiction. World J Gastroenterol. 2007 Aug 21. 13 (31):4161-7. [Medline].

Abramowitz L, Sobhani I, Benifla JL, Vuagnat A, Daraï E, Mignon M, et al. Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis Colon Rectum. 2002 May. 45 (5):650-5. [Medline].

Cheng CY, Li Q. Integrative review of research on general health status and prevalence of common physical health conditions of women after childbirth. Womens Health Issues. 2008 Jul-Aug. 18 (4):267-80. [Medline].

Stites T, Lund DP. Common anorectal problems. Semin Pediatr Surg. 2007 Feb. 16 (1):71-8. [Medline].

Alonso-Coello P, Mills E, Heels-Ansdell D, López-Yarto M, Zhou Q, Johanson JF, et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol. 2006 Jan. 101 (1):181-8. [Medline].

Mounsey AL, Henry SL. Clinical inquiries. Which treatments work best for hemorrhoids?. J Fam Pract. 2009 Sep. 58 (9):492-3. [Medline].

Perrotti P, Antropoli C, Molino D, De Stefano G, Antropoli M. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. 2001 Mar. 44 (3):405-9. [Medline].

Orsay C, Reichman EF. External hemorrhoid management. Reichman EF, ed. Emergency Medicine Procedures. 2nd ed. New York: McGraw-Hill; 2013. Chap 68.

Coates WC. Anorectal procedures. Roberts JR, Custalow CB, Thomsen TW, et al, eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 7th ed. Philadelphia: Elsevier; 2019. 904-16.

Jongen J, Bach S, Stübinger SH, Bock JU. Excision of thrombosed external hemorrhoid under local anesthesia: a retrospective evaluation of 340 patients. Dis Colon Rectum. 2003 Sep. 46 (9):1226-31. [Medline].

Greenspon J, Williams SB, Young HA, Orkin BA. Thrombosed external hemorrhoids: outcome after conservative or surgical management. Dis Colon Rectum. 2004 Sep. 47 (9):1493-8. [Medline].

Cavcić J, Turcić J, Martinac P, Mestrović T, Mladina R, Pezerović-Panijan R. Comparison of topically applied 0.2% glyceryl trinitrate ointment, incision and excision in the treatment of perianal thrombosis. Dig Liver Dis. 2001 May. 33 (4):335-40. [Medline].

Zuber TJ. Hemorrhoidectomy for thrombosed external hemorrhoids. Am Fam Physician. 2002 Apr 15. 65 (8):1629-32, 1635-6, 1639. [Medline]. [Full Text].

Brett Wallace Lorber, MD, MPH, FACEP Attending PhysicianTorrance Memorial Medical Center

Brett Wallace Lorber, MD, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Thrombosed External Hemorrhoid Excision

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